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ment of transdiagnostic and transcultural processes. Such assessments may better explain cultural variations of GAD compared to symptom checklists that assess symptoms that do not have cross-cultural equivalence.
The centrality of “thinking a lot” is easily identified in the etiology and mainte- nance of GAD, given that excessive worry is an essential diagnostic marker of GAD. What is likely to differ between cultural groups are the worry domains.
According to work conducted with Cambodian refugees, multiple worry domains include the following: finances for themselves and relatives in Cambodia, safety related to living in poor areas with ongoing violence, health concerns, catastrophic interpretations of somatic symptoms, and spiritual status of relatives who may be believed to be suffering because of culturally inappropriate burial due to missed opportunities for completing culturally indicated bereavement rites (61).
Aside from unique worry domains, Cambodians also attribute the consequences of worry in a culturally distinct manner. For instance, Cambodians have multiple concerns following a worry episode. Some examples of the feared impact of worry include the following: mental agitation, overheated and potentially damaged brain, and weakened mind and body. Further adverse consequences of worrying include poor memory, dizziness, propensity for khyâl attacks, cardiac arrest, stroke, and insanity (62). These feared consequences have emerged as linking factors between worry episodes and more severe psychopathology. Specifically, worry was associ- ated with posttraumatic stress disorder (PTSD) as suggested by a path analysis study exploring mechanisms that explain feared consequences of khyâl attacks (61).
This relationship between khyâl attacks and PTSD was explained by worry-induced somatic arousal, worry-induced catastrophic cognitions, worry-induced trauma recall, inability to stop worry, and irritability. Findings from this work suggest that all three transcultural and transdiagnostic mechanisms proposed in this chapter – i.e., “thinking a lot” (by way of worry and associated catastrophic cognitions), anxi- ety sensitivity (by way of worry-induced somatic arousal), and somatization (by way of discomfort from multiple interacting somatic sensations) – explained GAD- like symptoms and its association with more severe psychopathology such as PTSD.
A final consideration in conceptualizing GAD across cultures relates to the role of the socioeconomic and safety context a client is in. Specifically, it is essential to assess current stressors because they might be compounding worry and impacting the chronicity of its course. For cultural groups living in contexts of ongoing vio- lence, poverty, or structural inequities, assessing worry as “excessive” (a qualifier needed to diagnose GAD) may be more difficult as their worry could be adaptive for addressing true safety threats.
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approaches to sensitively assessing and addressing anxiety disorders take into account local and universal factors known to shape anxiety. Considering local CCDs with transcultural and transdiagnostic targets can provide a holistic conceptualization of how anxiety is experienced and expressed in different cultural groups. In turn, these transcultural processes are profoundly shaped by the local culture. These approaches to understanding anxiety were illustrated in case examples from Cambodian refugees, Latin American immigrants, and Japanese and Korean individuals.
The literature reviewed highlights the importance of assessing for transdiagnostic and transcultural factors that have been linked with variable presentation of anxiety disorders across cultural groups. Cognitive processes, such as “thinking a lot,” are promising constructs to assess as many anxiety disorders are theorized to have cogni- tive underpinnings. Relatedly, it is important to assess catastrophic cognitions that serve to maintain anxiety disorders. Anxiety sensitivity is a promising affective target for determining risk of developing anxiety disorders. Additionally, somatic presenta- tions are commonly reported among diverse cultural groups, so assessing a broad set of somatic sensations, along with the interpretation of these sensations, can enable more comprehensive recognition of problems.
While this chapter has synthesized current literature on three major anxiety disorders, much more research is needed in diverse cultural groups to comprehensively account for differences across all the anxiety disorders. Mixed-methods research that accounts for DSM 5 criteria alongside local idioms and syndromes is especially warranted for accu- rate understanding of culturally unique symptom presentations. Another limitation of the literature reviewed is that several unique ethnic groups are collectively studied as belonging to one cultural group. However, it is often untenable to disaggregate the spe- cific ethnic groups that constitute minority cultural groups due to challenges in acquiring sufficient sample sizes (23). Efforts to broaden research from comparative inquiries on specific ethnic groups to other understudied populations are needed.
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